Primary Care Office Visit Note Template

The Primary Care Office Visit Note template covers the visit most of a primary care day is made of. It moves through subjective with chief complaint, HPI, interval history, and adherence, an objective section with a vitals line, exam space, and a prompt for results reviewed and interpreted, an assessment block that gives each problem its own row for diagnosis, status, and reasoning, and a plan section for orders, medications, referrals, education, and the follow-up interval.

What makes it different from a blank SOAP box is that it is shaped around how office visit E/M is actually selected. You choose the level on either medical decision making or total time on the date of the encounter, never both, so the header carries a start, stop, and total time line, and the assessment asks for the reasoning behind each problem rather than a bare diagnosis list. The header also captures place of service, modifier, and telehealth consent for visits done remotely. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.